Nokea
The nurse’s assessment findings of the pregnant client include darkening of areola and nipple, presence of Goodell’s sign, leukorrhea, HR 124 bpm, dysuria, and heartburn. Of these findings, how many require further evaluation?
- A. 3
Correct Answer: 3
Rationale: There are three abnormal findings that require further evaluation. Leukorrhea needs to be distinguished from a vaginal infection, such as Candida albicans or a sexually transmitted infection. Heart rate can increase by 10 to 15 bpm during pregnancy, but an increase to 124 bpm is too high. Dysuria may be a sign of a UTI. Darkening of the areola and nipple, Goodell’s sign, and heartburn are normal findings during pregnancy and do not require further evaluation.
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The client, who is 12 days postpartum, telephones the clinic and tells the nurse that she is concerned that she may have an infection because her vaginal discharge has been creamy white for two days now. Which response by the nurse is correct?
- A. “You need to come to the clinic as soon as possible.”
- B. “You’ll need an antibiotic; which pharmacy do you use?”
- C. “Take your temperature and let me know if it is elevated.”
- D. “A creamy white discharge 10 days postpartum is normal.”
Correct Answer: D
Rationale: There is no need to be seen in the clinic; vaginal discharge that turns creamy white 10 days postpartum is normal. The client does not have an infection, and no antibiotic is necessary. There is no reason to take her temperature when the discharge is normal. Creamy white discharge 10 to 21 days postpartum is normal. Her lochia changed color on her 10th postpartum day.
The laboring client suddenly experiences a dramatic drop in the FHR from the 150s to the 110s. A vaginal exam reveals the presence of the fetal cord protruding through the cervix. What should be the nurse’s first intervention?
- A. Put continuous pressure on the presenting part to keep it off the cord
- B. Place the bed in Trendelenburg position
- C. Insert a urinary catheter and instill saline
- D. Continue to monitor the FHR
Correct Answer: A
Rationale: The nurse should first exert continuous pressure on the presenting part to prevent further cord compression. This is continued until birth, which is usually by cesarean section. The bed should be placed in Trendelenburg position to further prevent pressure on the cord, but only after pressure is placed on the presenting part. A catheter may be inserted and 500 mL of warmed saline instilled to help float the head and prevent further compression, but only after pressure is placed on the presenting part. The fetus is continually monitored throughout until birth.
The client admitted in preterm labor is told that an amniocentesis needs to be performed. The client asks the nurse why this is necessary when the HCP has been performing ultrasounds throughout the pregnancy. Which is an appropriate response by the nurse?
- A. “Your baby is older now, and an amniocentesis provides us with more information on how your baby is doing.”
- B. “An amniocentesis could not be Performed before 32 weeks, so you will be having this test from now until delivery.”
- C. “Your doctor wants to make sure that there are no problems with the baby that an ultrasound might not be able to identify.”
- D. “With your preterm labor your doctor needs to know your baby’s lung maturity; this is best identified by amniocentesis.”
Correct Answer: D
Rationale: The amniocentesis is being performed to determine fetal lung maturity. Once fetal lung maturity is determined, appropriate care can be planned, including administration of betamethasone, administration of tocolytics, or delivery of the baby. While an amniocentesis can provide fetal information that an ultrasound cannot, the rationale for the amniocentesis is to determine lung maturity. Stating additional information is too broad. An amniocentesis can be performed as early as 12 weeks’ gestation, not after 32 weeks. The amniocentesis is not being performed to identify fetal anomalies.
The nurse advises the client with constipation to increase intake of which food?
- A. High-fiber fruits and vegetables
- B. White rice
- C. Processed meats
- D. Sugary desserts
Correct Answer: A
Rationale: High-fiber fruits and vegetables promote bowel regularity, relieving constipation safely during pregnancy.
Which response by the nurse about Chadwick's sign is most accurate?
- A. It's a bluish discoloration of the cervix, vagina, and vulva that occurs as a result of the presence of an increased number of blood vessels.
- B. It's a softening of the cervix that occurs because of an increased amount of blood flowing to the reproductive organs.
- C. It's a dark brown line extending from the umbilicus to the symphysis pubis that occurs as a result of hormonal changes.
- D. None of the above
Correct Answer: A
Rationale: Chadwick's sign is the bluish discoloration of the cervix, vagina, and vulva due to increased vascularity, a probable sign of pregnancy.